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Top 100 Drugs > Contraindications > Flashcards

Contraindications Flashcards

1
Q

Adrenaline

A

✅No contraindications for cardiac arrest or anaphylaxis

❗️Caution when using for vasoconstriction in those with heart failure and at end artery sites e.g fingers and toes

💊Interactions: may cause widespread vasoconstriction in people on beta blockers

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2
Q

Glucocorticoids (systemic)

A

❗️caution in people with infection
❗️caution in children

💊 Cytochrome p450 inducers (⬇️ efficacy)
💊 NSAIDs - increased risk of peptic ulcers and GI bleeding
💊 Beta2 agonists/Diuretics/Theophylline - increased risk of hypokalaemia

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3
Q

Thiazide Like Diuretics

A

❌ Hypokalaemia
❗️Hyponatraemia
❗️Gout

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4
Q

Statins

A

❗️Hepatic impairment
❗️Renal impairment (lower dose)
❌ Pregnancy
❌ Breastfeeding

💊 Cytochrome p450 inducers - reduce metabolism of statins therefore more side effects. May need to reduce statin dose or temporarily withhold.
💊 Amlopidine

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5
Q

Clopidogrel

A

❌ active bleeding
❗️stop 7 days before elective surgery
❗️hepatic and renal impairment

💊is a pro-drug therefore cytochrome p450 inhibitors reduce efficacy
💊use lansoprozole over omeprazole for gastric protection
💊increased risk of bleeding with other antiplatelets, anticoagulants or NSAIDs

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6
Q

Antihistamines

A

❗️severe liver disease as sedating antihistamines may precipitate hepatic encephalopathy

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7
Q

5a-reductase

Finasteride

A

❌ Pregnant

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8
Q

Alpha blockers

Doxazosin, tamsulosin, alfuzosin

A

⁉️Postural hypotension- avoid

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9
Q

Acetylcholinesterase inhibitors

Donepezil, Rivastigmine

A 
❗️Asthma
❗️COPD
❗️Risk of peptic ulcers
❌ heart block
❌ sick sinus syndrome
❗️may worsen tremor in Parkinson’s

💊NSAIDs and corticosteroids may increase risk of peptic ulcer
💊 Antipsychotics increase risk of neuroleptic malignant syndrome
💊 B-blockers may contribute to heart block/bradycardia

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10
Q

B-blockers

Propanolol, bisoprolol, atenolol, metoprolol, carvedilol

A

❌Asthma as can cause bronchspasm
❗️heart failure start slow as can initially impair cardiac function ❗️Haemodynamic instability - avoid
❌ Heart block
❗️Hepatic Failure - reduce dose

💊❌Non-hydropyridine calcium channel blockers (e.g. verapamil, diltiazem) as can cause 💔

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11
Q

Acetylcysteine

A

None - even in hx of anaphylactoid rxn

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12
Q

Activated charcoal

A

⚠️ Persistent vomiting (risk of aspiration)

⚠️ Reduced gut motility (risk of obstruction)

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13
Q

Adenosine

A

Avoid in those who will not tolerate bradycardic effects:
❌Hypotension
❌Coronary ischaemia
❌decompensated heart failure

Avoid in those susceptible to bronchospasm
❌asthma
⚠️COPD

⚠️ Heart transplant

💊 Dipyridamole (an antiplatelet) blocks cellular uptake of adenosine which prolongs its effect therefore the dose should be halved.
💊Theophylline and aminophylline are competitive antagonists of adenosine receptors therefore reduce its effect and patients may require higher doses

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14
Q

Aldosterone antagonists

spironolactone, eplerenone

A

❌Severe renal impairments
❌Hyperkalaemia
❌Addison’s disease (who are aldosterone deficient)

Can cross placenta so ⚠️ in pregnancy

💊 Combo with other potassium elevating drugs e.g. ACE-i and ARBs increases risk of hyperkalaemia therefore monitor closely
💊❌ Potassium supplements

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15
Q

Alginates and antacids

Gaviscon, Peptac

A

⚠️Paediatric alginates should not be given with thickened milk preparations as can cause bloating and discomfort

⚠️Sodium and potassium containing preparations should be used with caution in patients with fluid overload or hyperkalaemia e.g. renal failure

⚠️Some preps contain glucose which can worsen hyperglycaemia in people with DM

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16
Q

Allopurinol

A

❌Acute attack of gout (if not already started)
❌Recurrent skin rash
❌Severe hypersensitivity to allopurinol

It is metabolised in liver and excreted by kidney therefore reduce dose in
⚠️Renal impairment
⚠️Hepatic impairment

💊Azathioprine active metabolite is metabolised by xanthine oxidase therefore increased toxicity risk if both given
💊Co-px with ACE-i or thiazides increases risk of hypersensitivity reactions

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17
Q

Aminoglycosides

gentamycin, amikacin, neomycin

A

Renal excretion - impt to monitor plasma drug concentrations to prevent renal, cochlear and vestibular damage, particularly in ⚠️neonates, ⚠️elderly patients and those with ⚠️renal impairment.

⚠️ Myasthenia gravis as can impair neuromuscular transmission

💊Loop diuretics or vancomycin increase risk of ototoxicity
💊Ciclosporin, platinum chemo, cephalosporins or vancomycin increase risk of nephrotoxicity

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18
Q

Aminosalicylates

mesalazine, sulfasalazine

A

❌ Aspirin hypersensitivity

💊Mesalazine tablets with pH-sensitive coating may interact with drugs e.g. PPI’s or lactulose that alter gut pH

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19
Q

Amiodarone

A

Avoid in patients with
⚠️severe hypotension
⚠️heart block
⚠️active thyroid disease

💊Loads of stuff but notable = digoxin, ditilazem, verapamil which get increased plasma concn that increases risk of bradycardia, AV block and heart failure. Halve the doses of these if start amidarone.

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20
Q

ACE-i

ramipril, lisinopril, perindopril

A

❌Renal artery stenosis
❌Acute kidney injury
⚠️pregnant or breastfeeding
⚠️CKD - use lower doses

💊Avoid potassium-elevating drugs
💊Other diuretics –> profound first-dose hypotension
💊NSAIDs increase risk of nephrotoxicity

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21
Q

ARBs

losartan, candesartan, irbesartan

A

❌Renal artery stenosis
❌Acute kidney injury
⚠️pregnant or breastfeeding
⚠️CKD - use lower doses

💊Avoid potassium-elevating drugs
💊Other diuretics –> profound first-dose hypotension
💊NSAIDs increase risk of nephrotoxicity

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22
Q

Antidepressants - SSRIs

citalopram, sertiriline, fluoxetine, escitalopram

A

⚠️epilepsy
⚠️peptic ulcer disease
⚠️young people (increased risk of self harm and suicide)
Metabolised by liver therefore ⚠️ hepatic impairment

💊❌ Monoamine oxidase inhibitors and ⚠️other serotergic drugs as may precipitate serotonin syndrome
💊 Consider gastroprotection with aspirin or NSAIDs as increased risk of bleeding
💊 Caution with anticoagulants as increased bleeding risk
💊Do not combine with drugs that prolong the QT interval e.g. antipsychotics

23
Q

Antidepressants - tricyclics and rltd drugs

Amtriptyline, lofepramine

A 
⚠️epilepsy
⚠️elderly
⚠️cardiovascular disease
Antimuscarinic effects may worsen condition in people with:
⚠️prostatic hypertrophy
⚠️glaucoma
⚠️constipation

💊❌ Monoamine oxidase inhibitors as both increase 5-HT and NA levels at the synapse and together they can precipitate hypertension and hyperthermia or serotonin syndrome.
💊Tricyclics can augment antimuscarinic, sedative or hypotensive adverse effects of other drugs

24
Q

Antidepressants, venlafaxine and mirtazapine

A

⚠️elderly
Consider dose reduction in people with ⚠️hepatic or ⚠️renal impairment
Venlafaxine should be used with caution in pts with ⚠️arrhythmias (e.g. due to ischaemic heart disease)

💊Other depressants in combo can increase risk of adverse effects including serotonin syndrome

25
Q

Antiemetics - D2 receptor antagnoists

metoclopramide, domperidone

A

To reduce risk of extrapyramidal effects metoclopramide should be prescribed for 5d max. Avoid in:
❌neonates ⚠️children ⚠️ young adults
Domperidone is contraindicated in patients with:
❌cardiac conduction abnormalities ⚠️severe hepatic impairment
Avoid both drugs in:
⚠️intestinal obstruction ❌perforation
Metoclopramide should be avoided in ⚠️Parkinson’s disease but domperidone okay

💊antipsychotics (increases risk of extrapyramidal side effects)
💊❌dopaminergic agents for Parkinson’s disease as it will antagonise their effects
💊❌drugs that prolong QT interval
💊❌drugs that inhibit cytochrome P450 inhibitors

26
Q

Antiemetics - H1 receptor antagonists

cyclizine, cinnarizine, promethazine

A

Due to sedating effect avoid in pts at risk of:
⚠️hepatic encephalopathy
⚠️prostatic enlargement (as susceptible to anticholinergic effects)

💊increased sedation effects e.g. benzos, opioids
💊increased anticholinergic effects e.g. ipratropium or tiotropium

27
Q

Antiemetics - 5-HT3 receptor antagonists

ondansetron, granisetron

A

Avoid in patients with ⚠️ prolonged QT interval

💊Avoid drugs that prolong the QT interval (e.g. antipsychotics, quinine and SSRIs)

28
Q

Antifungal drugs

nystatin, clotrimazole, fluconazole

A

Topical - no contraindications

Fluconazole - ⚠️liver disease, ⚠️reduce dose in renal impairment, ❌ pregnancy

💊fluconazole increases plasma concn of drugs metabolised by CYP enzymes (e.g. carbamazepine,, phenytoin, warfarin, dizepam, simvastatin and sulphonylureas)
💊reduce antiplatelet action of clopidogrel
💊increases risk of arrhythmias if with drugs that prolong QT interval (amiodarone, antipyschotics, quinine, quinolone, macrolides and SSRIs)

29
Q

Antihistamines - H1 receptor antagonists

cetirizine, loratidine, fexofenadine, chlorphenamine

A

Sedating antihistamines (e.g. chlorphenamine) should be avoided in ⚠️severe liver disease as may precipitate hepatic encephalopathy

30
Q

Antimotility drugs

loperamide, codeine phosphate

A

⚠️ Acute ulcerative colitis - as reduced peristalsis may increase risk of megacolon and perforation
⚠️C diff colitis possibility
⚠️acute bloody diarrhoea as may signify bacterial infection (risk of haemolytic-uraemic syndrome from E. coli)

31
Q

Antimuscarinics - bronchodilators

ipratropium, tiatropium, aclidinium, glycopyrronium

A

⚠️ Angle-closure glaucoma
⚠️ arrhythmias
⚠️ urinary retention

32
Q

Antimuscarinics - cardiovascular and GI uses

atropine, hyoscine butylbromide, glycopyrronium

A

⚠️ Angle-closure glaucoma
⚠️ arrhythmias (unless being used for bradycardia)

💊more pronounced when used with other antimuscarinics e.g. tricyclic antidepressants

33
Q

Antimuscarinics - GU uses

oxybutynin, tolterodine, solifenacin

A 
❌ UTI - therefore do urinalysis
⚠️ elderly as neurological side-effects can be problematic
⚠️dementia
⚠️angle-closure glaucoma
⚠️arrhythmias
⚠️urinary retention risk

💊more pronounced when used with other antimuscarinics e.g. tricyclic antidepressants

34
Q

Antipsychotics, first generation

haliperidol, chlorpromazine, prochlorperazine

A

⚠️ elderly - sensitive so use lower dose
⚠️ dementia - increase risk of death and stroke
⚠️ Parkinson’s disease - EPSE

💊 extensive list, careful with drugs that prolong the QT interval

35
Q

Antipsychotics - second generation

olanzapine, clozapine, risperidone

A

⚠️ cardiovascular disease
Clozapine:
❌ Severe heart disease
❌ Neutropenia

💊 Sedation may be more pronounced used with other sedating drugs
💊 Dopamine-blocking anti-emetics
💊 drugs that prolong the QT interval (amiodarone, quinine, macrolides, SSRIs)

36
Q

Antiviral drugs

aciclovir

A

⚠️ pregnant and ⚠️ breastfeeding (as crosses the placenta and expressed in breast milk) but often benefits outweigh risks
⚠️ severe renal impairment - as excreted by kidneys therefore reduce dose and frequency

37
Q

Antiplatelets - ADP-receptor antagonists

clopidogrel, ticagrelor, prasugrel

A

❌ active bleeding (stop 7 days before surgery)
⚠️ renal and hepatic impairment - esp where increased bleeding risk

💊CYP inhibitors (as clopidogrel is pro-drug metabolised by CYP enzymes, e.g. omeprazole [use lansoprazole instead], erythromycin, antifungals, SSRIs
💊 ticagrelor interacts with CYP inhibitors and inducers
Increased bleeding risk with:
💊antiplatelet drugs
💊anticoagulants
💊NSAIDs

38
Q

Antiplatelets - aspirin

A

❌ children under 16
❌aspirin hypersensitivity
❌3rd trimester pregnancy (may prematurely close ductus arteriosus)
⚠️ peptic ulceration (prescribe gastroprotection)
⚠️gout

💊caution with other antiplatelets and anticoagulants

39
Q

Azathioprine

A

Do TMPT phenotyping first
❌absent TMPT and careful with reduced TMPT
⚠️reduce dose in liver/renal impairment
⚠️pregnancy - teratogenic in animal studies

💊other immunosuppressants as increased risk of infection
💊xanthine oxidase inhibitors - allopurinol
💊myelosupppressive drugs as increase risk of leukopenia e.g. trimethoprim
💊warfarin dose may need adjusting

40
Q

β-blockers

bisoprolol, atenolol, propanolol, metoprolol, carvediol

A

❌asthma - as can cause bronchospasm (okay in COPD but use more selective bisoprolol, metoprolol)
❌heart block
⚠️heart failure - start low dose as can impair cardiac fxn
⚠️haemodynamic instability
⚠️hepatic failure

💊non-dihydropyridine calcium channel blockers (verapamil, diltiazem) as can cause heart failure, bradycardia and even asystole

41
Q

β2-agonists

Salbutamol, terbutaline, salmeterol, formoterol, indacaterol

A

❗️care with patients with CVD as tachycardia can provoke angina/arrhythmias

💊 β-blockers will reduce effects
💊 Use with theophylline and steroids can precipitate hypokalaemia

42
Q

Benzodiazepines

diazepam, temazepam, lorazepam, chlordiazepoxide, midazolam

A

⚠️ elderly need a lower dose
⚠️ avoid in resp impairment
⚠️avoid in neuromuscular disease e.g. myaesthenia gravis
⚠️avoid in liver failure as can precipitate hepatic encephalopathy (but if essential use lorazepam)

💊Concurrent use with CYP inhibitors may increase their effects (e.g. amiodarone, diltiazem, macrolides, fluconazole)

43
Q

Bisphosphonates

alendronic acid, zoledronic acid, disodium pamidronate

A

❌ Severe renal impairment (renally excreted)
❌ hypocalcaemia
❌ active upper GI disorder
⚠️ smokers and patients with dental disease as risk of jaw osteonecrosis

44
Q

Calcium and vitamin D

calcium carbonate, calcium gluconate, colecalciferol, alfacalcidol

A

❌ hypercalcaemia

⚠️💊Oral calcium reduces the absorption of many drugs including bisphosphonates, tetracyclines, levothyroxine
❌💊Do not deliver IV with sodium bicarbonate as -> precipitation

45
Q

Calcium channel blockers

nifedipine, amlodipine, verapamil, diltiazem

A

V&D:
⚠️poor left ventricular function
⚠️AV nodal conduction delay (can provoke complete heart block)
A&N:
❌Unstable angina as vasodilatation -> reflex tachycardia which increases myocardial oxygen damage
❌ Severe aortic stenosis

❌💊 β-blockers with V&D as both are negatively inotropic and chronotropic

46
Q

Carbamazepine

A 
⚠️ pregnancy (TAKE FOLATE)
❌ antiepileptic hypersensitivity syndrome
⚠️ hepatic disease
⚠️ renal disease
⚠️ cardiac disease

💊 Carbamazepine is a CYP enzyme inducer therefore reduces efficacy or other drugs metabolised by CYP (e.g. warfarin, oestrogens, progestogens)
💊 Carbamazepine is also metabolised by CYP enzymes so affected by CYP inhibitors (e.g. macrolides)
💊other antepileptic drugs
💊drugs that lower the seizure threshold (e.g. antipsychotics, tramadol)

47
Q

Cephalosporins and Carbapenems

cefalexin, cefotaxime, meropenem, ertapenem

A

⚠️Risk of C. diff infection
❌allergy to penicillin, ceph or carbapenem (anaphylactic reaction
⚠️epilepsy
⚠️renal impairment have to reduce dose

💊 can enhance effects of warfarin as gut flora that synth vit K are killed off
💊reduce efficacy of valproate

48
Q

Chloramphenicol

A 
❌ hypersensitivity
❌bone marrow disorders (personal or family hx)
❌pregnancy 3rd trimester (systemic)
❌breastfeeding
❌children <2 years
⚠️dose adjustment in hepatic impairment
49
Q

Corticosteroids (glucocorticoids), inhaled

beclometasone, budesonide, fluticasone

A

⚠️ COPD patients with hx of pneumonia

⚠️children - growth suppression

50
Q

Corticosteroids (glucocorticoids), topical

hydrocortisone, betamethasone

A

⚠️infection present

⚠️facial lesions

51
Q

Digoxin

A 
❌2nd degree heart block 
❌intermittent complete heart block
ventricular arrhythmias
⚠️reduce dose in renal failure
⚠️hypokalaemia/magnesaemia and hypercalcaemia increase toxicity (K+ competes with digoxin for Na+/K+ ATPase pump)

💊 Loop and thiazide diuretics can ppt hypokalaemia
💊Amiodarone, CCBs, spironolactone and quinine can increase plasma concn of digoxin therefore increase toxicity

52
Q

Dipeptidylpeptidase-4 inhibitors

sitagliptin, linagliptin, saxagliptin

A 
❌hypersensitivity
❌Type 1 diabetes
❌ Ketoacidosis
❌ Pregnancy
❌ Breastfeeding
⚠️elderly
⚠️hx of pancreatitis
⚠️renal-impairment

💊 risk of hypoglycaemia with other antidiabetic drugs (e.g. sulfonylureas and insulin)
💊β-blockers may mask hypoglycaemic sx
💊efficaacy reduced by drugs that increase blood glucose (prednisolone, thiazide loop diuretics)

53
Q

Direct oral anticoagulants

apixaban dabigatran, edoxaban, rivaroxaban

A 
❌ active bleeding
❌ risk of major bleeding
❌pregnancy
❌breastfeeding
⚠️ hepatic or renal disease (excreted by multiple routes)

💊other antithrombotic agents (e.g. heparin, antiplatelets, NSAIDs)
💊anticoagulant effect ↑ by macrolides, protease inhibitors and fluconazole
💊anticoagulant effect ↓ by rifampicin and phenytoin

Top 100 Drugs (4 decks)

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